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Wednesday, December 8, 2010

The Obstetrical BS Series: The Induction Seduction

Perhaps one of the biggest pregnancy myths circulating today is that "Doctors won't induce unless it's medically necessary!" I wish I had a nickel for every time I hear someone say that. I find that the more people I talk to, the definition of "medical" and "necessary" gets fuzzier and fuzzier. I've even heard medical professionals - labor and delivery nurses, for God's sake! - say this. Maybe not on your watch, or in your hospital. But please get your head out of your butt and put down your Kool-Aid: this is a very real problem that often does nothing more than trade one set of complications for another, all in an effort to prevent them.

It's hard to resist, I know: you're big and huge, cranky and tired, and sick of getting up to pee every 45 minutes all night long. Your ankles are swelling, your mother is bugging you about when the baby is coming, and you just want it over with already. Who, at this point, doesn't?

It's estimated that one in five women is induced, and some numbers suggest it's higher than that. It's probably hard to estimate how many of those are 'social' inductions, but it's not uncommon for a doctor to at least offer an induction at some point during the pregnancy, regardless of medical "need." While most think that a doctor only brings it up as the due date comes and goes, it's increasingly clear that some OB's will discuss it early and often.
“We’ll just make sure you deliver by 40 weeks! Don’t worry, almost *EVERY* woman gives birth before her due date!” – OB to mother.
"At my 39 week appointment, my doctor said she wanted to induce me the next week if I did't go into labor on my own. I asked why and she seem surprised I didn't want to have the baby ASAP...I was also due in late Dec., so it's certainly a possibility that the induction was at least partially for doctor's convenience."
When I asked friends in the birth community what their experiences were, one reader says her doctor brought up induction before she was even out of the first trimester. She thought it was odd, considering how she was going for a VBAC and induction is not recommended.  Out of all the responses I've had so far, only one person said her OB didn't mention it and was respectful of her birth plan not to induce unless it was medically necessary.

The most common reasons cited for induction are "big baby," low fluid, and post-dates. We have great diagnostic tools (sarcasm) that can tell us how big that baby will be or how much fluid there is, only sometimes it's off - by a lot. One reader stated that her baby was estimated at above 11 pounds, and agreed to do a cesarean - later finding out her baby's actual weight was just over 7 pounds. The famous line "Fat squishes!" is true: lots of women find that it's easier to push out a squishy, chubby baby than one who is smaller, with sharper, bonier angles. I think the common misconception is that bigger babies will hurt more, somehow "tear you up" and are generally indicative of miserable deliveries. That idea is probably deeply rooted more in the way labor is managed: your position, as well as the baby's, might have more to do with it than sheer size alone.

I'll never forget the eve of one particularly interesting labor - I could hear the mother crying out while laboring as I made my pharmacy rounds. I was stunned to see that she hadn't ordered an epidural - I mean, doesn't every laboring mother request one? but was relieved because that meant I didn't have to make one, either. LOL Then as I filled her prescription for ibuprofen two days later I looked down across the counter to see her lugging a kid out in his carseat - a kid that already looked three months old - and realized, This woman had no epidural. I can't remember, but I think he was nearly 11 pounds. And he wasn't the first of her big babies, either.

This was probably the first of many encounters that shaped my perceptions of birth. That yes, you can labor without drugs, and you can even deliver a "big baby," too.

Another reader said her friend was being induced because she was tired of being pregnant. Most of the moms I knew were approaching due dates - my neighbor had her first last year and was due around a holiday. A good friend was experiencing heart problems throughout her first pregnancy, but apparently they were not grave enough to exclude her from having a vaginal birth. She was, however, induced at 38 weeks, and told me later that she still doesn't know why. (Her baby was born at the beginning of June, so if you add two weeks to the calendar, that lands you around Father's Day. Perhaps someone didn't want to miss a cookout or outing with dad?) To make up for it, her second was nearly born in the car. :)

In reading some pregnancy books, I find it alarming that some consider an 8 pound baby to be "big." Others give or take at least a pound and a half, thankfully. I wonder what our definition of big hinges on - perhaps it's still a leftover from the days of when women restricted their dietary intake and smoked more, creating smaller babies that were perceived as 'easier' on the mother.

Low fluid - which some pregnancy sites almost approach with dire concern - is increasingly becoming another dubious reason. Gloria LeMay considers it a "scam " and I agree - it seems like one more "medically necessary" reason to move things along and get it over and done with. In some cases, low fluid can be remedied by simply drinking more fluids and making sure you're not dehydrated, which is an easy fix compared to the process of inducing labor.

Another disturbing trend is for women facing inductions to ask strangers on internet chat rooms, "What can I expect when I get induced tomorrow?" Even Dr. Amy agrees that induction is a very serious matter, and isn't something the patient should walk away from the office knowing nothing about. I asked my Memorial Day-induced neighbor if her doctor had told her the risks and disadvantages, and she said she had. But I can still find countless sources where women are completely and totally uninformed about the process, from all angles. When looking for a desirable answer in which to seek comfort, they usually won't choose the one that says, "Don't do it - mine was a disaster because my baby wasn't ready and I had a cesarean!" but will pick the one that says what they want to hear: "I had all my children induced and I did just fine!!"

In this sense, there is something to that old "blame the mother" argument. Women who blindly go into things uninformed don't even know enough to make the best decision for themselves or their babies, and therefore can't really make any decisions - because their doctor has essentially taken that power away from them. Anyone who tries to inform them otherwise is perceived as 'snarky' or branded as the Arm-Hair Braiding Lunatic, which is really unfortunate. If an induction is necessary, I don't think any doctor should allow his patient to go home without first reviewing a list of the pros and cons. That is truly informed consent.

From what I've read, an alarming number of women do not fully, if at all, understand the risks of induction. They do not understand even when they are truly necessary. Some of the more interesting comments I've heard include:
"After all the hoopla of the appointment [heartbeat check, growth check, etc...] and after my internal; he said "Meet me at the hospital at 6 am tomorrow morning." I asked him why and he said "Meet me at the hospital at 6 am tomorrow moprning. Baby's ready. We induce."
"I feel every woman is different and if she is at least 38 weeks she should be able to make her decision rather to get induced. it shouldn't be the doctor's choice as long as the baby is healthy."  
"My second was born at 38 weeks perfectly healthy. Now my doctor wants me to wait 39/40 weeks to give birth to my third baby. I mean, sheesh, what's the hold up? No one should have to wait the whole 42 weeks or more unless due to medical reasons concerning the baby. I agree that we should be able to decide as long as we have made it to 37/38 weeks with no complications."
An overwhelming number of women, when asked about the risks, said they were not sure of the risks, but thought it was "pretty" safe. Only one person said "Run! Run far away!" and gave a detailed horror story of how she was treated like dirt by her doctor and hospital staff, including them ganging up on her and getting her visiting family to push her into it. She added that hospital staff "kicked her mother out of the OR and tried to remove my brother from the hospital when they asked too many questions." (And as if you couldn't guess, her answer received a thumbs down.)

Even more so than that, they realize even less how it could impact their baby. Just because you hit the magic 37 week mark, it does not mean your baby's lungs are fully mature. Studies have shown that babies born by elective cesarean had complications - with one fetal death - up until the 39th week.

And even though elective cesarean and elective induction are two totally different things, they can sometimes lead to the same outcome. Studies have also shown that for first-time mothers, inductions can lead to an increased risk of cesarean, which plants that seed of doubt from the get-go: that my body is broken. That "failure to progress" diagnosis sticks with a patient oftentimes, and can totally change the way birth happens in the future. Rightly so, many women are starting to realize that "failure to progress" often means "failure to wait," and no where does this make more sense than in a failed induction. The mother has no guide - no prior births - on which to base her experience, and therefore doesn't know if she can even go into labor on her own or not. My own sister-in-law, herself a nurse, was socially induced with two pregnancies (because her doctor was going on vacation), and one birth nearly ended in cesarean with suction and shoulder dislocation. By the time she was approaching labor with her third, she had no idea what to expect.

One comment I read came from a mom of five who was expecting her sixth baby. All of the prior births had been induced, and this time she was ready to head to the hospital simply because she was dilated. She admitted that she had no idea what going into labor on her own was like - even after five kids.

While no one is arguing that sometimes inductions aren't truly necessary, the abuse of them is like treating something with a solution when we don't even have a problem. Not only are we fostering a completely false notion of what birth can be like, but we couple it with the idea that our bodies are somehow inadequate, broken, and incapable of handling what is otherwise a normal physiological process.

"Obstetricians have always been trained to believe that pregnancy and labor are disasters waiting to happen." - Dr. Bruce Flamm

More reading:
Why Do Doctors Induce Labor?
Cesarean Deliveries Rise Alongside Rate of Induced Labor
5 Reasons to Avoid an Induction of Labor
Reasons to Induce Labor
Saying "No" to Induction
What is a Bishop's Score and How Does it Relate to Inducing Labor?
Australian woman visited by police after failing to show up for induction

Part 1: The Obstetrical BS Series: Redefining Normal 


MamaOnABudget said...

I'm one of the apparent "lucky ones" who, when I told my doctor I wouldn't consider an induction at my 40w appointment, was told "I don't even bring the word up until you're past 42 weeks."

I firmly believe (and will repeat it whenever necessary) that a lot of the getting the birth I wanted came from working with a Family Practitioner - not an OB (and I've got it even better this time with a homebirth midwife - an option that wasn't available to me in SD when my older 2 were born).

The Deranged Housewife said...

I would SO birth with my family doc - a DO - we've had this conversation about inductions, etc. before and he seems to be hands-off and reasonable, but he doesn't deliver babies. Your doctor sounds great!

Anonymous said...

My OB with my 5th born suggested an induction in the first trimester because I could plan for childcare. I had a previous birth with the baby NOT being caught due to no one calling the OB until I was at 8cm. (I had been hanging around the hospital for over 2 hours, so there was no reason a doctor couldn't be there....). I went from 4cm to 9cm pretty quick and baby came out on the bed with the 4th born, so she thought the 5th born needed her presence. Well, I refused, and baby was born without her. It took again a while for nurses to call, and it wasn't clear who to call since she had charted she wanted to be there. In the time they called off one doc and got her, she came but just to catch the placenta. The nurses caught though, and all was well. I just don't understand why you'd induce a mom who can do it without help...I live only about 20 mintues from the hospital and have a history of being there in time. An induction is not a guarantee the doctor will be available to catch either.

The Deranged Housewife said...

Isn't it sad that they basically prey on you with the whole "But what about childcare?!" thing. In my situation, we have no family close by and my mom was coming from five hours away. She stayed with us a week prior to my due date both times, and for the second baby, just as we were about to tell her she could go home and we'd call, I went into labor. That time she was there allowed us to catch up, her to help with the kids and me to rest up and stuff. But induction, thank God, was never an option for me as I was planning VBACs.

It's sad that they only want an OB present so somebody gets credit for the birth. Our babies are seen as dollar signs, even though they probably could (and often do!) come out just fine in those situations.

Anonymous said...

Another pretty lucky one here. My first two came just fine on their own-early even. With my third my blood pressure was skyhigh at my 39 week appointment. He knew I didn't want to be induced, but also knew that preeclampsia was coming, just not how quickly it would get there. My doctor was concerned and gave me the option of going for blood work and monitoring or get induced the following morning. He could have just made me go right to the hopsital I suppose. I did get induced, but he took it slow and totally respected my wish for no pain meds. He even told the nurse not to mention the e word to me. And as for childcare-I had wonderful neighbors that were on standby and they were able to watch my 1st at short notice for my 2nd (at 5:00am).

Sara said...

The doctor that ended up being there for the birth of my daughter (although he let me catch her!) told me at my 37 week checkup that the office started talking induction around 41.5 weeks. I just nodded, thinking in my head "yeah, and I'm not coming in for that". I think my office was pretty good in that respect, though. They may have induced a mom who asked at 40 weeks, but I was NEVER pressured to induce. I went into labor spontaneously on my due date and she was born 5 hours later!